_____________________
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ACCOUNT NUMBER /SUFFIX
MEMBER NAME
_____________________________
LAST 6 OF VIN, VEHICLE YEAR, MAKE, MODEL
Authorization to Release Loan Payoff Information and Certificate of Title
I (We), the undersigned owner(s) of the above referenced collateral do hereby request and
authorize, America’s First Federal Credit Union to release loan balance and/or payoff
information to _____________________________ in order to process an insurance claim.
I (We), understand and agree that upon receipt of insurance proceeds, America's First
Federal Credit Union is authorized to release the Certificate of Title to the said insurance
company. I (We) further understand and agree that the amount of any claim paid by an
insurance company is solely determined by the insurance company. It is further understood
that I (we) will remain liable for any remaining balance due to America's First Federal Credit
Union after payment of any insurance claim.
I (We) hereby indemnify and hold harmless, America’s First Federal Credit Union, its
agents, employees, management and Board of Directors from any and all liability, costs,
damages or causes of action that may arise as a result of any such loss occurring from the
release of the Certificate of Title and loan information by me (us) to the insurance company
named above.
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Signature
_________
Date
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Signature
_________
Date
Revision 02/2014